Evolving Management of Acute Pulmonary Embolism with Extracorporeal Membrane Oxygenation—A Narrative Review

Acute pulmonary embolism (APE) carries significant 30-day mortality and morbidity. When APE is characterized by progressive hypoxia, hypotension, and right ventricular dysfunction, the risk of cardiovascular collapse and cardiac arrest is high, and intervention is recommended. As a result, there has been increasing impetus to utilize extracorporeal membrane oxygenation (ECMO) to provide rapid oxygenation support, immediate reduction in right ventricular (RV) overload, and hemodynamic support. Veno-arterial-ECMO modality is deployed to provide hemodynamic stability and restore tissue oxygenation and provides a bridge to recovery from percutaneous and open APE therapy. While many patients are placed on ECMO for a short period of time to treat APE, applying ECMO over an extended period pf time carries substantial multisystem morbidity due to systemic inflammatory response, hemorrhagic stroke, renal dysfunction, and bleeding. It appears that the initiation of ECMO alone, with or without administration of systemic thrombolysis, will not improve outcomes over conventional therapy for high-risk APE. The current literature demonstrates that ECMO is best paired with open or percutaneous thrombectomy to reduce or eliminate the clot burden and rapidly stabilize cardiovascular status; these dual outcomes translate into patient survival. However, a series of meta-analyses have not demonstrated that the use of ECMO in hemodynamically unstable APE results in a significant survival advantage compared to patients treated without ECMO.